Abstract The timing and approach to the restoration of intestinal continuity in emergent lower gastrointestinal surgery remains controversial. The authors sought to provide an evidence-based review of the treatment options for the restoration of intestinal continuity during emergency surgery in the setting of trauma, obstruction, and peritonitis. A search of MEDLINE, PubMed, and the Cochrane Database of Collected Reviews was performed. Abstracts were reviewed to determine their scientific merit. We then performed a complete evaluation of selected articles. A directed search of the embedded references from the primary articles was also performed in select circumstances. Recommendations and treatment algorithms were based on consensus conclusions of the data. A total of 128 articles were reviewed and analyzed for this article. The decision regarding when and how to restore intestinal continuity in emergent lower gastrointestinal surgery is complex and requires a thorough understanding of the underlying pathology, careful consideration of patient factors, and intimate knowledge of available treatment options.